The Cognitive Therapy Rating Scale – a rite of passage?

as an External Examiner I found it painful to watch videos of trainees trying to ensure their interview with a client was CTRS (or its’ successor the Revised Cognitive Therapy Rating Scale) compliant. I vividly remember one Course Leader giving a student a score above the competence threshold of 36 (see R-CTRS Manual, link at end of blog ), despite the student barely making eye contact with the client – the latter was busy leaving through the 12 item (each scored 0-6) scale on his lap! Unfortunately institutions were obliged to use it, and students groaned in silence. Before another cohort of trainees endures this rite of passage, those that have the courage to, should consider that the R-CTRS may cause more problems rather than it solves i.e that it is, iatrogenic.

Life Before the CTRS

In the seminal study of CBT for depression by Rush, Beck, Kovacs and Hollon (1977) they did not use the CTRS. Later when Steve Stradling and I conducted a randomised controlled trial comparing individual CBT, group CBT and treatment as usual, [Behavioural Psychotherapy, 18, 1-19]  we simply followed Beck’s protocol, p409-411 (1979) Cognitive Therapy of Depression, by Beck, Rush, Shaw and Emery., published by John Wiley and Sons to achieve good results.

The Poor Predictive Value of the R-CTRS

The CTRS has only been evaluated in a sample of depressed clients undergoing cognitive therapy [Shaw et al (1999)] , therapists scores on this did not  predict outcome on self-report measures the Beck Depression Inventory or the SCL-90 (a more general measure of psychological  distress) however it did predict outcome on the clinician administered Hamilton Depression Scale predicting just 19% of the variance in outcome, but it was the structure parts of the scale (setting of an agenda, pacing, homework) that accounted for this 19% not items measuring socratic dialogue etc. The authors concluded: ‘The results are, however, not as strong or consistent as expected’When the CTRS was first evaluated the results were not compelling’ . I enlarged on this previously in my blog ‘The Mis-Selling of the R-CTRS’


Since my earlier blog I have more recently blogged ‘Jump Through Our Hoops an Make No Difference To Client Outcome’, in which I noted an IAPT study that had used the R-CTRS to predict outcome and found that there was no relationship to outcome.

Cavalier Usage of The R-CTRS

Studies using the R-CTRS tend to be cavalier. In a study comparing BA and CBT, Richards et al (2016) used the R-CTRS but these authors did not report how this or indeed the competence measure for BA related to outcome. Richards et al said that though both modalities were equally effective in treating depression, but BA was to be preferred because it was cheaper to train therapists in BA. They further claim that the CBT therapists were competent with a mean score of 37.9 on the R-CTRS ( but this score is almost identical to the threshold of 36 in the R-CTRS Manual deemed necessary for a competent therapist) so on this metric half of the CBT therapists were not competent. Thus there has been a meaningless implementation of CBT. Paradoxically it may be that the CBT therapists performance had been made worse by having to use the R-CTRS.

Spinning The R-CTRS

Given the paucity of evidence for the utility of the R-CTRS for depression and possible negative side effects one would expect that it would not have been applied to other disorders. Unfortunately trainees are asked to apply it to whatever the client’s complaint or ‘problem descriptor’ as IAPT would have it. Little wonder that trainees are stressed by its’ usage.

Revised Cognitive Therapy Rating Scale

Richards et al (2016)

Dr Mike scott

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